Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions

Abstract

Fibreoptic tracheal intubation is a useful technique in patients whose tracheas are dif®cult to intubate. 66 69 However, there are two major dif®culties with this technique. The ®rst is location of the glottis and insertion of a ®brescope into the trachea. Induction of general anaesthesia (with or without neuromuscular block) causes the soft palate, tongue and epiglottis to approximate to the posterior pharyngeal wall, 64 and thus little air space is left in the oropharynx for manoeuvring the tip of the ®brescope to locate the glottis. 58 The second dif®culty is insertion of a tube over the ®brescope into the trachea. There have been reports of failed tracheal intubation despite successful insertion of a ®brescope into the trachea. 67 89 To solve the ®rst dif®culty, several manoeuvres (such as thrusting the jaw forward, extension of the head, or traction of the tongue) have been proposed, and airway intubators (such as the Berman, 17 Ovassapian 66 and Williams 87 ) have been developed. In addition, there have been comprehensive articles discussing effective ways of teaching ®brescopy. 58 66 69 85 In contrast, there have been no textbooks or reviews which comprehensively deal with the second dif®culty, of advancing a tracheal tube over a ®brescope. Therefore, the main aim of this review article is to analyse the incidence of, causes of and possible solution to, the dif®culty in advancing a tube over a ®brescope into the trachea. Problems associated with dif®cult intubation over a ®brescopeDif®culty in ®breoptic intubation is associated with two major problems. The ®rst is apnoea. Time taken to intubate the trachea, and thus the duration of apnoea, is generally markedly longer for ®breoptic intubation than intubation using a laryngoscope. 74 80±82 As a consequence, stress responses, such as the increase in the heart rate and blood pressure, are more likely to be greater during ®breoptic intubation. 80±82 If apnoea continues unduly, the patient may become hypoxic. 56 It is particularly awkward if, after successful insertion of a ®brescope into the trachea despite considerable dif®culty in a patient with a dif®cult airway, it is still dif®cult to advance a tube over the scope into the trachea and the arterial haemoglobin oxygen saturation starts to decrease.The second problem associated with dif®cult ®breoptic intubation is damage to the upper airway. Repeated attempts at inserting a ®brescope into the trachea and advancing a tube over the scope increase the risk of injury to the larynx and surrounding tissues, leading to bleeding from, or oedema of, the tissues. Although rare, complete airway obstruction could occur during attempts at ®breoptic intubation even when the patient is not anaesthetized. 18 59 What tends to be ignored is that at no time during insertion of a tracheal tube over a ®brescope can the tip of the tube be seen directly. Therefore, a tracheal tube should be advanced over a ®brescope with great caution, particularly in patients with pathological changes to the glottis or surrounding tissues. 44 ...

Comparison of fibrescope guided intubation via the classic laryngeal mask airway and i‐gel in a manikin*

“…The merit of this device is that it may reduce the chance of hold-up at the cross bars of the LMA Classic [7] as the AIC fits snugly over the fibrescope. In addition, railroading the tube over the AIC is likely to be easier than when using a fibrescope alone because of the greater external diameter of the AIC and consequent reduction of the gap between an AIC and a tracheal tube [8]. A 2009 survey of all anaesthetic department in the UK (64% response rate) found that only 50% (87 ⁄ 175) of the departments had the AIC available for use (Evans H, Hodzovic I, Latto IP.…”

“…This device is likely to reduce the chance of hold-up of the AIC at the cross bars of the LMA Classic [7] as it fits snugly over the fibrescope. In addition, railroading the tube over the AIC is likely to be easier than when using a fibrescope alone because of the greater external diameter of the AIC and consequent reduction of the gap between the AIC and the tracheal tube [8].…”

Are videolaryngoscopes useful for nasotracheal intubation?

“…The fiberoptic bronchoscope is regarded as the most reliable tool for nasotracheal intubation, but considerable skill and knowledge are required to achieve a smooth tracheal intubation [5,6]. In addition, its routine use may be impractical, partly because of the high cost of purchasing and maintaining the device.…”

Anaesthetic Challenges in a Pediatric Patient With Klippel Feil Syndrome Undergoing Surgery in Prone Position

“…[6] There was also a failure in fiber-optic intubation on two separate occasions. [7] We decided to do a conventional laryngoscopy without cervical extension and documentation of Cormack-Lehane score, as this patient is likely to come for further surgeries, due to the visualization Cormack-Lehane III of the vocal cords the patient was intubated.…”